8/17/2019 Peripheral Vascular Disease McGinnis

1/21

Peripheral Vascular Disease

Principles and Practice

8/17/2019 Peripheral Vascular Disease McGinnis

2/21

8/17/2019 Peripheral Vascular Disease McGinnis

3/21

Risk Factor odi"ication

• !ipid anagement

• #eight anagement

• Smoking Cessation• $lood Pressure Control

• Physical Activity

8/17/2019 Peripheral Vascular Disease McGinnis

4/21

Pathology o" Atherogenesis

•   %Response to &n'ury( )heory

  Alteration in endothelial cell layer *hich may

be to+ic, mechanical, hypo+ic, or in"ectious

•   -arly pla.ue "ormation can be seen in second

and third decades o" li"e as lipid streaking

•  Arterial enlargement

•  Anatomic distribution  Constant at areas o" bi"urcation

8/17/2019 Peripheral Vascular Disease McGinnis

5/21

Classi"ication o" !imb &schemia

• Functional

• /ormal blood "lo* at rest, but cannot beincreased in response to e+ercise 0 Claudication

• )hree main clinical "eatures  Pain is al*ays e+perienced in "unctional muscle

unit

  &t is reproducibly precipitated by a consistentamount o" e+ercise

  Symptoms are promptly relieved by stoppingthe e+ercise

8/17/2019 Peripheral Vascular Disease McGinnis

6/21

Classi"ication o" !imb &schemia

• Chronic critical limb ischemia

  Recurring ischemic pain at rest that

persists "or more than 1 *eeks andre.uires regular analgesics *ith an ankle

systolic pressure o" 23 mm Hg or less

  4lceration or gangrene o" the "oot or toes

8/17/2019 Peripheral Vascular Disease McGinnis

7/21

Classi"ication o" !imb &schemia

• &t is &P5R)A/) to di""erentiate these types o"

patients because

• Patients *ith claudication can be treated initially*ithout surgery 0 -+ercise program, Risk

reduction

• Patients *ith rest pain, gangrene, or ulceration

are candidates "or revasculari6ation

8/17/2019 Peripheral Vascular Disease McGinnis

8/21

Chronic 5cclusive !o*er -+tremity

Disease

• Patients *ith claudication

• Have lo* risk o" limb loss 0 Annual risk o"

mortality and limb loss 0 27 and 87• ore than hal" o" patients *ill improve or

symptoms remain stable

• 13 0 937 undergo surgery "or progressiono" symptoms

8/17/2019 Peripheral Vascular Disease McGinnis

9/21

Chronic 5cclusive !o*er -+tremity

Disease

• Patients *ith critical ischemia 0 rest pain,

gangrene, or tissue breakdo*n are at high

risk "or limb loss

• Patients should undergo angiographic

evaluation "or potential revasculari6ation

8/17/2019 Peripheral Vascular Disease McGinnis

10/21

 Aortoiliac 5cclusive Disease

• 5"ten present *ith complaints o" buttock, hip, or

thigh claudication

• &n men, impotence may be present in 93:237 o"

patients• 5nly a small percent ;837< o" patients have

disease con"ined to 'ust the distal aorta and

common iliac segments

• =3 7 o" patients *ill have more di""use disease

involving e+ternal iliac and>or "emoral vessels

8/17/2019 Peripheral Vascular Disease McGinnis

11/21

 Aortoiliac 5cclusive Disease

• /oninvasive Vascular Studies

• Help to improve diagnostic accuracy

• Physiologic .uanti"ication o" severity o"disease

• ay serve as baseline "or "ollo*:up

•  Angiography "or patients *ith limb

threatening ischemia

8/17/2019 Peripheral Vascular Disease McGinnis

12/21

 Aotoiliac 5cclusive Disease

Surgical )reatment

•  Aortobi"emoral $ypass

• Cross Femoral $ypass 0 Fem:Fem

bypass

•  A+illo"emoral $ypass

• Percutaneous Angioplasty

8/17/2019 Peripheral Vascular Disease McGinnis

13/21

Femoral:Popliteal:)ibial 5cclusive Disease

Surgical )reatment

• Femoral 0 Popliteal $ypass

  Above ?nee or $elo* ?nee $ypass

• Femoral 0 )ibial $ypass  Anterior, Posterior tibial or Peroneal

• Femoral 0 Dorsalis Pedis $ypass

• $ypass Conduits and )echni.ue  /onautogenous vs@ Vein gra"ts

8/17/2019 Peripheral Vascular Disease McGinnis

14/21

Carotid Artery 5cclusive Disease

• Symptoms

  )&A

  CVA

  Amaurosis Fuga+  Resolving /eurologic De"icits• /5) Symptoms

  Di66iness

  Vertigo  emory !oss

  !ight Headedness

8/17/2019 Peripheral Vascular Disease McGinnis

15/21

Carotid Artery 5cclusive Disease

• &maging Studies

  Carotid Duple+ 4ltrasound

  Angiography  C) Scan

  R&>RA

8/17/2019 Peripheral Vascular Disease McGinnis

16/21

Carotid Artery 5cclusive Disease

Surgical &ndications

• Symptomatic

  Carotid Stenosis 237 in patients *ithipsilateral )&A, Amaurosis, or R/D

  Patients *ith lesser degrees o" stenosis can beconsidered "or operation i" they have "ailedmedical therapy, large ulcerations orcontralateral occlusion

•  Asymptomatic  &ndications less clear but generally reserved "or

patients *ith B3:==7 Stenosis

8/17/2019 Peripheral Vascular Disease McGinnis

17/21

 Abdominal Aortic Aneurysm

• /atural History

  -nlarge and rupture

  -mboli6ation  A:V Fistula

  & Fistula

 

8/17/2019 Peripheral Vascular Disease McGinnis

18/21

 Abdominal Aortic Aneurysm

• Follo*ing rupture o" AAA

  5nly 237 o" patients arrive at the

hospital alive

  17 die be"ore operation

  17 die in the post operative period

  5verall mortality o" E3:=27

8/17/2019 Peripheral Vascular Disease McGinnis

19/21

 Abdominal Aortic Aneurysm

• ost important risk "actor "or rupture is

ma+imal transverse diameter 

  AAA 2 cm 0 8:97 per year 

  AAA 2:E cm 0 B:887 per year 

  AAA E cm 0 13 7 per year 

• Symptomatic AAA are at increased risk o"rupture as *ell

8/17/2019 Peripheral Vascular Disease McGinnis

20/21

 Abdominal Aortic Aneurysm

• Diagnosis

  4ltrasound

  C) Scan  R&

  Arteriography

8/17/2019 Peripheral Vascular Disease McGinnis

21/21

 Abdominal Aortic Aneurysm

• Selection o" patients "or repair 

  a+imal diameter 2 cms@

• )ypes o" repair   5pen repair vs@ -ndovascular